Gastric full-thickness suturing during EMR and for treatment of gastric-wall defects (with video)

Endoscopic full thickness resection: techniques, applications, outcomes

INTRODUCTION

Endoscopic full-thickness resection (EFTR) represents a pivotal advancement in the minimally invasive treatment of gastrointestinal lesions, offering a novel approach for the management of lesions previously deemed challenging or unreachable through conventional endoscopic techniques.

AREAS COVERED

This review discusses the development, methodologies, applications, and clinical outcomes associated with EFTR, including exposed and device-assisted EFTR, the integration of endoscopic mucosal resection with EFTR in hybrid techniques, and the collaborative approach between laparoscopic and endoscopic surgery (LECS). It encapsulates a comprehensive analysis of the various EFTR techniques tailored to specific lesion characteristics and anatomical locations, underscoring the significance of technique selection based on the lesion's nature and situational context.

EXPERT OPINION/COMMENTARY

The review underscores EFTR's transformative role in expanding therapeutic horizons for gastrointestinal tumors, emphasizing the importance of technique selection tailored to the unique attributes of each lesion. It highlights EFTR's capacity to facilitate organ-preserving interventions, thereby significantly enhancing patient outcomes and reducing procedural complications. EFTR is a cornerstone in the evolution of gastrointestinal surgery, marking a significant leap forward in the pursuit of precision, safety, and efficacy in tumor management.

Comparison of safety and short-term outcomes between endoscopic and laparoscopic resections of gastric gastrointestinal stromal tumors with a diameter of 2-5 cm

BACKGROUND AND AIM

Developments of endoscopic techniques brought the possibility of endoscopic resection for gastrointestinal stromal tumors (GISTs) of larger sizes. We aim to compare safety and short-term outcomes between endoscopic and laparoscopic resections of gastric GISTs with a diameter of 2-5 cm.

METHODS

This is a single-center, retrospective cohort study. The clinical data, perioperative conditions, and the adverse events of patients who underwent endoscopic or laparoscopic resection for gastric GIST of 2-5 cm in Zhongshan Hospital, Fudan University, from January 2016 to December 2020 were retrospectively reviewed.

RESULTS

A total of 346 patients were reviewed; 12 patients who failed to accomplish the planned procedure were excluded; 182 underwent laparoscopic resection; and 152 underwent endoscopic resection. Significant differences exist in the tumor size between the laparoscopic group (3.43 ± 0.86 cm) and the endoscopic group (2.78 ± 0.73 cm) (P < 0.01). Compared with laparoscopic resection, endoscopic resection was associated with faster recovery (P < 0.01), shorter hospital stays (P < 0.01), and lower cost (P < 0.01). The incidence of Clavien-Dindo grade II-V adverse events in the endoscopic group (3/152) was significantly lower than that in the laparoscopic group (12/182) (P = 0.04). After a propensity score matching analysis, the endoscopic group showed similar incidences of complications with the laparoscopic group, while the advantages over laparoscopic resection in postoperative hospital stay, time to first oral intake, and hospitalization expenses remained significant (P < 0.01).

CONCLUSIONS

Endoscopic resection is a safe and cost-effective method for 2-5 cm of gastric GISTs compared with laparoscopic resection.

Current endoscopic closure techniques for the management of gastrointestinal perforations

Acute gastrointestinal perforations occur either from spontaneous or iatrogenic causes. However, particular attention should be made in acute iatrogenic perforations as timely diagnosis and endoscopic closure prevent morbidity and mortality. With the increasing use of diagnostic endoscopy and advances in therapeutic endoscopy worldwide, the endoscopist must be able to recognize and manage perforations. Depending on the size and location of the defect, a variety of endoscopic clips, stents, and suturing devices are available. This review aims to prepare and guide the endoscopist to use the right tools and techniques for optimal patient outcomes.

Resection of the gastric submucosal tumor (G-SMT) originating from the muscularis propria layer: comparison of efficacy, patients' tolerability, and clinical outcomes between endoscopic full-thickness resection and surgical resection

Background and aims

Endoscopic full-thickness resection (EFTR) has been increasingly applied in the treatment of gastric submucosal tumors (G-SMTs) with explorative intention. This study aimed to compare the efficacy, tolerability, and clinical outcomes of EFTR and surgical intervention for the management of muscularis propria (MP)-derived G-SMTs.

Methods

Between September 2011 and May 2019, the clinical records of patients with MP-derived G-SMTs undergoing EFTR at our endoscopic unit were collected. A cohort of people with primary MP-derived G-SMTs treated by surgery was matched in a 1:1 ratio to EFTR group with regard to patients’ baseline characteristics, clinicopathologic features of the tumor and the procedure date. The perioperative outcomes and follow-up data were analyzed.

Results

In total, 62 and 62 patients were enrolled into the surgery and EFTR group, respectively, with median follow-up of 786 days. The size of G-SMTs (with ulceration) ranged from 10 to 90 mm. For patients with tumor smaller than 30 mm, surgery and EFTR group presented comparable procedural success rate (both were 100%), en bloc resection rate (100% vs. 94.7%), tumor capsule rupture rate (0% vs. 5.3%), and pathological R0 resection rate (both were 100%). EFTR had a statistically significant advantage over surgery for estimated blood loss (3.12 ± 5.20 vs. 46.97 ± 60.73 ml, p ≤ 0.001), discrepancy between the pre- and postprocedural hemoglobin level (5.18 ± 5.43 vs. 9.84 ± 8.25 g/L, p = 0.005), bowel function restoration [1 (0–5) vs. 3 (1–5) days, p ≤ 0.001], and hospital cost (28,617.09 ± 6720.78 vs. 33,963.10 ± 13,454.52 Yuan, p = 0.033). The patients with tumor larger than 30 mm showed roughly the same outcomes after comparison analysis of the two groups. However, the clinical data revealed lower en bloc resection rate (75.0% vs. 100%, p = 0.022) and higher tumor capsule rupture rate (25.0% vs. 0%, p = 0.022) for EFTR when compared to surgery. The procedure time, duration of postprocedural fasting and antibiotics usage, and hospital stay of the two groups were equivalent. The occurrence rate of adverse events within postoperative day 7 were 74.2% and 72.6% after EFTR and surgery, respectively (p = 1.000). No complications occurred during the follow-up.

Conclusion

For treatment of MP-derived G-SMTs (with or without ulceration), our study showed the feasibility and safety of EFTR, which also provided better results in terms of procedural blood loss, the postoperative bowel function restoration and cost-effectiveness when compared to surgery, whereas the surgery was superior in en bloc resection rate for G-SMTs larger than 30 mm. The postprocedural clinical outcomes seemed to be equivalent in these two resection methods.

Comparison of two methods for endoscopic full-thickness resection of gastrointestinal lesions using OTSC

Background and aims: The aim of this study was to compare and analyze the feasibility and safety of two methods of endoscopic full-thickness resection (EFTR) for the management of challenging epithelial and subepithelial neoplasms that are not amenable to resection techniques.Material and methods: This was a retrospective case series study of patients who underwent one of two methods of EFTR, resection using ESD knives and post-resection closure with OTSC (Group 1), or closure with OTSC and secondary EFTR with snare (Group 2).Results: Of 11 patients, six were in Group 1 and five in Group 2. The mean time of the EFTR procedure was 76.83 ± 34.97 min in Group 1 which is significantly longer than that of Group 2 (p = .0128). The mean time of OSTC closure and length of hospital stay of Group 1 were also longer compared to Group 2, but the difference was not significant. Complete resection (R0) and technical success rates of Group 1 and Group 2 were 83.3% and 100% (p = .338), respectively. VAS scores of Group 1 immediately after the operation and after 24 h are significantly higher than those of Group 2 (p = .047 and p = .009, respectively). In Group 1, one patient had delayed perforation which led to fever and pneumoperitoneum, and one patient developed abdominal pain. No complications associated with the endoscopic procedure were observed in Group 2.Conclusion: EFTR of pre-resection closure are potentially faster compared with the concept of applying closure after EFTR. Larger prospective controlled studies comparing these two techniques are warranted in the future.

Closing the Gaps: Endoscopic Suturing for Large Submucosal and Full-Thickness Defects

This article is a systematic review of relevant literature on endoscopic suturing as a primary closure technique for large submucosal and full-thickness defects after endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and endoscopic full-thickness resection (EFTR). A comprehensive literature search was conducted through 2016 by using PubMed, to find peer-reviewed original articles. The specific factors considered were the procedural indications and details, success rates, clinical outcomes including complications, and study limitations. Six original articles were included in the final review: two with non-human subjects and four with human subjects. The mean success rate of endoscopic suturing was 97.4% (100% for human subjects and 95.4% for non-human subjects). The procedural time ranged from 7 to 89 min. The average size and depth of lesions were 2.71 cm (3.74 cm [human] and 1.96 cm [non-human]) and 1.52 cm, respectively. The technique itself had no reported impact on mortality. In conclusion, endoscopic suturing is a minimally invasive technique for the primary closure of defects caused by EMR, ESD, and EFTR, with a high success and low complication rate.

A novel grasp-and-loop closure method for defect closure after endoscopic full-thickness resection (with video)

BACKGROUND

Endoscopic full-thickness resection (EFTR) is a minimally invasive method for en bloc resection of gastrointestinal (GI) lesions originating from the muscularis propria layer. Successful closure of the wall defect is a critical step.

OBJECTIVE

The aim of this study was to evaluate the feasibility and efficacy of a novel and simplified endoscopic grasp-and-loop (GAL) closure method using an endo-loop assisted with grasping forceps for defect closure.

METHODS

From January 2015 to March 2016, 13 patients with submucosal tumors (SMTs) originating from the muscularis propria (MP) layer underwent EFTR and were enrolled in this study. After successful tumor resection, an endo-loop was anchored onto the circumferential margin of the gastric defect with grasping forceps assistance and tightened gently. Patient characteristics, tumor size, en bloc resection, and postoperative complications were evaluated.

RESULTS

Of the 13 lesions in the stomach, two were located in the greater curvature of the mid-upper body, 11 were located in the fundus. The endoscopic GAL closure method was successfully performed after EFTR in all the 13 patients without laparoscopic assistance. The mean procedure time was 43.5 min (range 20-80 min), while the GAL closure procedure took a mean of 9.4 min (range 3-18 min). The mean resected lesion size was 1.5 cm (range 0.5-3.5 cm). Pathological diagnoses of these lesions were 11 gastrointestinal stromal tumors (GISTs) and two leiomyomas. No major adverse events occurred during or after the procedure. All the patients were discharged after a mean time of 2.4 days (range 1-4 days). No residual lesion or tumor recurrence was found during the follow-up period (median, 5 months; range, 1-15 months).

CONCLUSIONS

The endoscopic GAL closure method is feasible, effective, and safe for closing the gastric defect after EFTR in patients.

[Endoscopic full-thickness resection]

Conventional endoscopic resection techniques such as endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) are powerful tools for the treatment of gastrointestinal (GI) neoplasms. However, those techniques are limited to the superficial layers of the GI wall (mucosa and submucosa). Lesions without lifting sign (usually arising from deeper layers) or lesions in difficult anatomic positions (appendix, diverticulum) are difficult - if not impossible - to resect using conventional techniques, due to the increased risk of complications. For larger lesions (>2 cm), ESD appears to be superior to the conventional techniques because of the en bloc resection, but the procedure is technically challenging, time consuming, and associated with complications even in experienced hands. Since the development of the over-the-scope clips (OTSC), complications like bleeding or perforation can be endoscopically better managed. In recent years, different endoscopic full-thickness resection techniques came to the focus of interventional endoscopy. Since September 2014, the full-thickness resection device (FTRD) has the CE marking in Europe for full-thickness resection in the lower GI tract. Technically the device is based on the OTSC system and combines OTSC application and snare polypectomy in one step. This study shows all full-thickness resection techniques currently available, but clearly focuses on the experience with the FTRD in the lower GI tract.

Endoscopic Submucosal Dissection (ESD) and Related Techniques as Precursors of "New Notes" Resection Methods for Gastric Neoplasms

Endoscopic full-thickness resection for subepithelial tumors is one of the more attractive proposed methods for less-invasive transluminal surgery but remains challenging in terms of safety and feasibility. Currently, laparoscopic endoscopic cooperative surgery is thought to be a more clinically acceptable approach. In targeting cancers, however, more advanced nonexposure techniques are required to avoid the risk of iatrogenic tumor seeding. By combining these techniques with possible regional lymphadenectomy using sentinel node navigation surgery, an ideal minimally invasive, function-preserving gastric resection can be achieved even in possible node-positive cancers. Further development for this type of advanced endoscopic surgery is expected.

Non-Exposure, Device-Assisted Endoscopic Full-thickness Resection

Recent developments have expanded the frontier of interventional endoscopy toward more extended resections following surgical principles. This article presents two new device-assisted techniques for endoscopic full-thickness resection in the upper and lower gastrointestinal tract. Both methods are nonexposure techniques avoiding exposure of gastrointestinal contents to the peritoneal cavity by a "close first-cut later" principle. The full-thickness resection device is a novel over-the-scope device designed for clip-assisted full-thickness resection of colorectal lesions. Endoscopic full-thickness resection of gastric subepithelial tumors can be performed after placing transmural sutures underneath the tumor with a suturing device originally designed for endoscopic antireflux therapy.

Endoscopic Suturing, an Essential Enabling Technology for New NOTES Interventions

Natural orifice transluminal endoscopic surgery (NOTES) was developed as a new, minimally invasive approach for various interventions inside the peritoneal cavity. Since the first reports of NOTES animal interventions, various devices have been used for closure of the transluminal entrance site. This article reviews the most commonly used endoscopic closure devices and advantages of the latest generation of endoscopic suturing devices enabling reliable, surgical-quality closure of the full-thickness gastrointestinal wall defects.

The Endoscopic Treatment of Iatrogenic Gastrointestinal Perforation

BACKGROUND

Iatrogenic gastrointestinal perforation is a life-threatening complication that arises very rarely in routine endoscopic procedures, with an incidence of 0.03-0.8%. It is more likely in highly complex and invasive therapeutic interventions. In certain situations, endoscopic closure of the perforation and treatment with antibiotics can obviate the need for emergency surgical repair.

METHODS

This review is based on pertinent articles retrieved by a selective literature search in PubMed and on a relevant position paper.

RESULTS

Existing clinical studies of treatment for iatrogenic gastrointestinal perforation are mainly retrospective and uncontrolled. No randomized and controlled trials have been performed to date. If the perforation is discovered soon after it arises, endoscopic treatment can be considered. Gastrointestinal perforations that are less than 30 mm in size can be closed with a clip. In the esophagus, expanding metal stents can be used as well. Clip application is successful in 80-100% of cases of gastrointestinal perforation, and the perforation remains permanently closed in 60-100% of cases. Reports on the endoscopic treatment of esophageal perforation show mixed results, with closure rates of roughly 90% and clinical success rates of roughly 80%. If endoscopic treatment is not possible, timely laparoscopic or open surgical repair is needed.

CONCLUSION

The endoscopic treatment of iatrogenic perforations is safe and reliable. Success depends on early detection, adequate endoscopic closure with properly mastered technique, and the early initiation of concomitant antibiotic treatment, which must be continued for a full course. Most patients who are treated in this way do not need emergency surgery.

Endoscopic full-thickness resection: Current status

Conventional endoscopic resection techniques such as endoscopic mucosal resection or endoscopic submucosal dissection are powerful tools for treatment of gastrointestinal neoplasms. However, those techniques are restricted to superficial layers of the gastrointestinal wall. Endoscopic full-thickness resection (EFTR) is an evolving technique, which is just about to enter clinical routine. It is not only a powerful tool for diagnostic tissue acquisition but also has the potential to spare surgical therapy in selected patients. This review will give an overview about current EFTR techniques and devices.

Application of clips assisted with foreign body forceps in defect closure after endoscopic full-thickness resection

BACKGROUND

This study was designed to evaluate the feasibility and efficacy of metallic clips assisted with foreign body forceps closing the gastric wall defect after endoscopic full-thickness resection (EFR) for gastric submucosal tumors (SMTs).

METHODS

Eighteen patients with gastric SMTs originated from the muscularis propria were treated by EFR between September 2012 and June 2014. Twelve patients underwent endoscopic closure of the gastric wall defects after EFR with endoloop and metallic clips (endoloop string suture method, ESSM), and six patients with clips and foreign body forceps (clips assisted with foreign body forceps clip method, CFCM).

RESULTS

No significant differences existed between the two groups in terms of demographics, clinical characteristics, and the size of the gastric wall defects. The average time spent in closing the gastric wall defects (14.83 ± 1.94 min for the CFCM group and 22.42 ± 5.73 min for the ESSM group) and hospitalization fees of the CFCM group were significantly lower than those of the ESSM group. The average hospitalization time of the two groups had no statistical significance. No single case had surgical intervention or complications, such as gastric bleeding, perforation, peritonitis, or abdominal abscess.

CONCLUSION

The CFCM and the ESSM are safe and effective techniques for gastric defect closure after EFR for gastric SMTs. Because of the "chopsticks effect," the CFCM more suitable for the lesions located at the gastric fundus, the greater curvature or anterior wall of the gastric body and gastric antrum.

Natural orifice transluminal endoscopic surgery in humans: feasibility and safety of transgastric closure using the OTSC system

BACKGROUND

NOTES is a technique in which an operation is performed within the body without a skin incision by using a natural body orifice to provide access. The principal challenge of transgastric NOTES procedures is still the feasibility and safety of access closure. Currently, there are very limited data regarding the closure of transgastric NOTES in humans, and the standard method and device for closure has not been defined. Herein, we evaluate the feasibility and safety of gastric closure after NOTES procedures in humans with the over-the-scope clip (OTSC).

METHODS

Review of collected data of patients underwent transgastric NOTES in prospective clinical studies between April 2010 and March 2014 focused on the gastric closure with the OTSC.

RESULTS

A total of 43 patients underwent transgastric

NOTES

36 patients with an acute appendicitis, six patients with a prophylactic bilateral salpingo-oophorectomy, and one patient with uterus myomatosus. In all 43 cases, the incision of the gastric wall and the endoscopic access to the abdominal cavity succeeded without any difficulty. After performing transgastric procedures, it was possible to close the access by OTSC in all cases. There were all in all three adverse events: one major (Clavien-Dindo Grade III) and two minor (Clavien-Dindo Grades I and II).

CONCLUSION

Even if we could show for the first time in more than 40 consecutive patients that there is a safe approach for closing the transgastric access, it is absolutely necessary that further investigation in clinical settings has to be done to establish clear indications and guidelines for the use of transgastric NOTES.

Propofol sedation during endoscopic treatment for early gastric cancer compared to midazolam

Endoscopic submucosal dissection (ESD) has been proposed as the gold standard in the treatment of early gastric cancer because it facilitates a more accurate histological assessment and reduces the risk of tumor recurrence. However, the time course of ESD for large gastric tumors is frequently prolonged because of the tumor size and technical difficulties and typically requires higher doses of sedative and pain-controlling drugs. Sedative or anesthetic drugs such as midazolam or propofol are used during the procedure. Therapeutic endoscopy of early gastric cancers can often be performed with only moderate sedation. Compared with midazolam, propofol has a very fast onset of action, short plasma half-life and time to achieve sedation, faster time to recovery and discharge, and results in higher patient satisfaction. For overall success, maintaining safety and stability not only during the procedure but also subsequently in the recovery room and ward is necessary. In obese patients, it is recommended that the injected dose be based on a calculated standard weight. Cooperation between gastroenterologists, surgeons, and anesthesiologists is imperative for a successful ESD procedure.

Modified laparoscopic intragastric surgery and endoscopic full-thickness resection for gastric stromal tumor originating from the muscularis propria

BACKGROUND

This study aimed to evaluate the feasibility and security of the modified laparoscopic intragastric surgery (MLIGS) and the endoscopic full-thickness resection (EFR) for the treatment of gastric stromal tumors (GSTs) originating from the muscularis propria.

METHODS

The study population was 18 patients with GSTs of the intraluminal muscularis propria layer. Eight were treated by MLIGS performed according to the following procedures: (1) gastroscopy was used to expose and confirm the location of the tumor; (2) a laparoscope light was placed in the cavity using the trocar at the navel, with the remaining two trocars penetrating both the abdominal and stomach walls; (3) the operation was performed in the gastric lumen using laparoscopic instruments with gastroscope monitoring, and the tumor was resected; (4) the tumor tissue was removed orally using a grasping forceps; (5) and the puncture holes and perforation in the stomach were sutured using titanium clips. The remaining 10 patients were treated by EFR, which involved (1) injection of normal saline into the submucosa and precutting of the mucosal and submucosal layer around the lesion, (2) a circumferential incision as deep as the muscularis propria around the lesion, (3) an incision into the serosal layer around the lesion, (4) completion of full-thickness incision to the tumor, (5) closure of the gastric wall defect with clips.

RESULTS

The GSTs all were resected completely. The two groups did not differ significantly in terms of tumor size, hospital stay, or abdominal pain time. But in the MLIGS group, the operation time and blood loss were significantly decreased compared with the EFR group. No postoperative complications occurred in the MLIGS group, whereas one peritoneal abscess occurred in the EFR group. The pathology of all the resected specimens showed GST. No case of implantation or metastasis was found.

CONCLUSIONS

Both MLIGS and EFR are feasible and effective treatments for GSTs from the muscularis propria. Moreover, both are minimally invasive.

Complete defect closure of gastric submucosal tumors with purse-string sutures

BACKGROUND

Gastric submucosal tumors (SMTs) originating from the muscularis propria layer are treated endoscopically. Successful closure of the wall defect is a critical step. This study evaluated the safety and feasibility of the endoscopic purse-string suture (EPSS) method using an endoloop and several metallic clips after endoscopic full-thickness resection (EFTR) or perforation due to endoscopic submucosal dissection (ESD).

METHODS

From December 2009 to April 2013, 30 patients with SMTs originating from the muscularis propria layer who received EFTR or ESD were retrospectively analyzed. After successful tumor resection, an endoloop was anchored onto the circumferential margin of the gastric defect with several metallic clips and tightened gently. Patient characteristics, tumor size, en bloc resection, and postoperative complications were evaluated.

RESULTS

For all 30 patients, EPSS was successfully performed after EFTR or perforation due to ESD. The mean diameter of the resected specimen was 1.9 cm. No severe complications occurred during or after the procedure. The lesions were healed 1 month after the procedure, as confirmed endoscopically.

CONCLUSION

The EPSS method using an endoloop and clips is an effective and safe technique for closing the gastric defect after EFTR or perforation due to ESD.

Feasibility study of secure closure of gastric fundus perforation using over-the-scope clips in a dog model

BACKGROUND AND AIM

Gastric fundus perforation is a serious complication of endoscopic mucosal resection and endoscopic submucosal dissection performed for the removal of early gastric cancers or subepithelial tumors. The novel over-the-scope clip (OTSC) has recently been found to be effective for closing gastrointestinal-tract perforations and accesses for natural orifice transluminal endoscopic surgery. However, feasibility studies of OTSCs in gastric fundus perforation are still lacking. The aim of this study was therefore to demonstrate the feasibility of endoscopic closure of gastric fundus perforation using the OTSC system in a dog model.

METHODS

Gastric fundus perforations were created by needle-knife electrocautery in seven dogs. The perforations were then closed using the OTSC clipping system. Stomach distension was maintained by maximum insufflation with air and methylene blue solution (500 mL) was instilled to submerge the closed perforation. Leaks were detected laparoscopically.

RESULTS

Perforations were closed in all seven cases with a mean time of 18.5 ± 6.4 min (11-28 min). Twin Grasper assistance failed to release the OTSCs in two of the seven cases (2/7, 28.6%) because of difficulties associated with the J-maneuver (retroflexion of endoscope) required for the gastric fundus procedure, and OTCS were forced into place by suction. Minor leakage was observed in one case (1/7, 14.3%). No damages related to the clip system were found during postmortem examinations.

CONCLUSIONS

Despite difficulties associated with the J-maneuver of the endoscope, this small series demonstrated that sufficient closure of gastric fundus perforation could be achieved using the OTSC system.

Efficacy and safety of transgastric closure in natural orifice transluminal endoscopic surgery using the OTSC system and T-bar sutures: a survival study in a porcine model

BACKGROUND

In natural orifice transluminal endoscopic surgery (NOTES), procedures are performed with an endoscope passed through a natural orifice. One of the most important factors that will determine the future of transgastric NOTES is obtaining a reliable closure of the access site. The aim of this study was to determine the efficacy and safety of transgastric closure using the over-the-scope clip (OTSC) system or T-bar sutures.

METHODS

We performed a survival study that included 15 pigs. A standardized transgastric approach to the peritoneal cavity and a peritoneoscopy were performed. The gastrotomy was closed using the OTSC system or T-bar sutures. The gastrotomy closure was tested for leaks with the methylene blue test. All animals were observed for 2 weeks before they were sacrificed and necropsy was performed. Histopathological examination of tissue samples retrieved from the access sites was performed.

RESULTS

There were no perioperative complications. The methylene blue test did not demonstrate any leakage of fluid. Necropsy after 2 weeks confirmed completeness of gastric closure in all animals with full-thickness healing and no spillage of gastric contents into the peritoneal cavity. No differences between the OTSC system and T-bar sutures were observed.

CONCLUSION

We observed no differences between the efficacy and safety of the OTSC system and those of T-bar sutures used in closing gastric incisions in NOTES. Both methods are safe and effective.

Endoscopic full-thickness resection of submucosal gastric tumors

BACKGROUND AND AIMS

Endoscopic full-thickness resection (EFTR) is a minimally invasive method for en bloc resection of gastrointestinal lesions, such as early cancer or submucosal tumor. The aim of this pilot study was to evaluate a novel EFTR prototype device for full-thickness resection of the gastric wall containing artificial submucosal lesions.

METHODS

Six artificial submucosal tumors were surgically created in the gastric submucosa by implanting 8-mm cork beads in anesthetized pigs. EFTR of the lesions was attempted using a prototype device which consists of a large transparent plastic cap, loaded onto the tip of the endoscope, into which the submucosal lesion and the surrounding gastrointestinal wall can be pulled by using suction, a grasping forceps, or a dedicated anchoring device. An over-the-scope clip (OTSC) can be deployed underneath the submucosal lesion and a pre-loaded snare is used for EFTR above the OTSC.

RESULTS

The median procedure time was 15 min (interquartile range 11-22). Successful resection of the artificial submucosal lesion was achieved in 4/6 (67%) cases. Successful EFTR of the gastric wall was achieved in 3/6 (50%) cases. In all cases, the OTSC closed the EFTR site completely.

CONCLUSIONS

Gastric EFTR using the novel EFTR prototype device is feasible in a live animal model. The technique can achieve a full-thickness gastric wall and submucosal tumor resection with reliable closure of the gastric wall, but further refinements of the technique and device are necessary in order to reliably resect submucosal lesions, especially larger ones.

Transgastric small bowel resection with the new multitasking platform EndoSAMURAI™ for natural orifice transluminal endoscopic surgery

BACKGROUND

Recently, natural orifice transluminal endoscopic surgery has been introduced using flexible endoscopic technology. Traditional endoscopes lack several capabilities that are needed to perform complex surgical procedures safely. The purpose of this study was to evaluate the new multitasking platform for transgastric small bowel resection including dissection of the mesentery and suturing an anastomosis.

METHODS

A new prototype of endoscopic multifunctional platform, EndoSAMURAI™ (ES), was tested. A standardized in vitro setting was established with segments of small bowel and an anastomosis was sutured with the device and compared with that by stapler (ST) and hand-sewn (HS). Leak pressure was measured. In addition, the system was tested in an experimental in vivo situation by performing a transgastric small bowel segmental resection under general anesthesia.

RESULTS

Median time to perform an anastomosis in the bench test was 41 min; median leak pressure for the anastomosis by ES was 14 mmHg, by ST 25 mmHg, and HS 15 mmHg. For the in vivo study, the median total procedure time was 110 min and leak pressure 53 mmHg. These results show that the end-to-end small bowel anastomosis can be sutured sufficiently.

CONCLUSIONS

This study has shown that with a multifunctional platform such as the EndoSAMURAI™, the majority of complex surgical tasks can be performed if technically independently moving instruments can be used via an ergonomic workstation interface that allows for laparoscopy-like maneuvers by the operator. Even with the shortcomings of the prototype, it was possible to perform an anastomosis of the small bowel of acceptable quality within a reasonable time.

Endoscopic full-thickness resection in the colon by using a clip-and-cut technique: an animal study

BACKGROUND

Although endoscopic resection techniques have been established for definitive therapy of mucosal neoplasia, complete histopathological assessment or resection of subepithelial lesions is not reliably possible.

OBJECTIVE

To overcome these limitations, a novel endoscopic full-thickness resection (EFTR) and closure technique was developed.

DESIGN

Animal survival study.

ANIMALS

Eight female domestic pigs.

INTERVENTIONS

Two-centimeter artificial distal colonic lesions were created endoscopically. EFTR of the lesions was attempted using a prototype device, which consists of a large transparent plastic cap with a preloaded snare and a modified over-the-scope clip. After the procedure, half of the animals were killed after 7 days, and the other half after 28 days.

MAIN OUTCOME MEASUREMENTS

Complete resection (all markings included in the specimen), technical success, complication rates, and wound healing on follow-up autopsy and histology.

RESULTS

EFTR of healthy colonic tissue was possible in all cases; 2 additional clips had to be placed for complete closure in 1 case. In 1 animal, the preloaded closure failed, and the animal was prematurely killed. All other animals had an uneventful postoperative course. Necropsy and histopathological evaluation demonstrated well-healed resection sites with no evidence of intra-abdominal infection or inadvertent organ inclusion.

LIMITATIONS

Animal model, resection of healthy tissue.

CONCLUSION

This novel device allows for reliable full-thickness resection and closure of 2-cm specimens of the colonic wall in a single procedure as well as reliable wound healing of EFTR defects.

Colonic endoscopic full-thickness biopsies: from the neuropathological analysis of the myenteric plexus to the functional study of neuromuscular transmission

BACKGROUND

Better understanding of the pathophysiological mechanisms involved in severe dysmotility disorders is crucial to improve patient management and identify novel therapeutic targets. Recent studies suggested that endoscopic full-thickness biopsies (eFTBs) could be developed as an alternative to surgical biopsies. However, currently it remains unknown whether eFTBs would allow myenteric plexus analysis on whole mounts and the evaluation of neuromuscular transmission.

OBJECTIVE

To determine with eFTB specimens the ability to analyze on whole mounts the key parameters of the myenteric plexus, ie, ganglia and neurons, and to perform functional evaluation of neuromuscular transmission.

DESIGN

An experimental pilot study in 6 pigs was conducted in accordance with French institutional guidelines.

INTERVENTION

Under general anesthesia, pigs underwent a rectosigmoidoscopy. In each pig, an eFTB was performed at 25, 30, and 35 cm from the anal margin with an EMR-based technique. Tissue specimens were immediately processed for immunohistochemical and/or functional ex vivo analysis of neuromuscular transmission. In 2 pigs, over-the-scope clips were used to seal the perforation.

MAIN OUTCOME MEASUREMENTS

Feasibility of obtaining specimens containing myenteric plexus and muscularis propria, quantitative and standardized immunohistochemical evaluation of ganglia and myenteric neurons, ex vivo assessment of neuromuscular transmission and its pharmacology, and closure rate (ancillary study).

RESULTS

Adequate tissue specimens were obtained in 100% of the procedures, on average, in 6±2 minutes. Immunohistochemical analysis of a whole mount of the myenteric plexus showed that each eFTB contained 14±5 ganglia and 1562±1066 myenteric neurons. In circular muscle strips, electrical field stimulation or exposure to a pharmacological agent induced a specific tissue response. A successful closure was achieved in 50% of cases.

LIMITATIONS

Nonsurvival study; safety of the procedure needs to be specifically assessed and compared with recently published data.

CONCLUSIONS

We demonstrate, for the first time, that full-thickness biopsy specimens obtained by using an endoscopic approach allow the performance of a precise study of the ENS phenotype on whole mounts of the myenteric plexus and the performance of functional studies such as evaluation of neuromuscular transmission. However, further studies are warranted to identify the optimal and safest endoscopic procedure before application of eFTB in humans.

Endoscopic full-thickness resection without laparoscopic assistance for gastric submucosal tumors originated from the muscularis propria

BACKGROUND

This study was designed to evaluate the clinical efficacy, safety, and feasibility of endoscopic full-thickness resection (EFR) for gastric submucosal tumors (SMTs) originated from the muscularis propria.

METHODS

Twenty-six patients with gastric SMTs originated from the muscularis propria were treated by EFR between July 2007 and January 2009. EFR technique consists of five major procedures: (1) injecting normal saline into the submucosa and precutting the mucosal and submucosal layer around the lesion; (2) a circumferential incision as deep as muscularis propria around the lesion by the endoscopic submucosal dissection (ESD) technique; (3) incision into serosal layer around the lesion with Hook knife; (4) completion of full-thickness incision to the tumor including the serosal layer with Hook, IT, or snare by gastroscopy without laparoscopic assistance; (5) closure of the gastric-wall defect with metallic clips.

RESULTS

EFR was successfully performed in all 26 patients without laparoscopic assistance. The complete resection rate was 100%, and the mean operation time was 105 (range, 60-145) min. The mean resected lesion size was 2.8 (range, 1.2-4.5) cm. Pathological diagnosis of these lesions included gastrointestinal stromal tumors (GISTs) (16/26), leiomyomas (6/26), glomus tumors (3/26), and Schwannoma (1/26). No gastric bleeding, peritonitis sign, or abdominal abscess occurred after EFR. No lesion residual or recurrence was found during the follow-up period (mean, 8 months; range, 6-24 months).

CONCLUSIONS

EFR seems to be an efficacious, safe, and minimally invasive treatment for patients with gastric SMT, which makes it possible to resect deep gastric lesion and provide precise pathological diagnosis of it. With the development of EFR, the indication of endoscopic resection may be expanded.

Endoscopic diagnosis and treatment of gastric glomus tumors

BACKGROUND

Although gastric glomus tumors are usually benign lesions, occasional malignant transformation has been reported. Thus, complete resection of the gastric glomus tumor is necessary.

OBJECTIVE

To provide a better understanding of the endoscopic features of this rare entity with an emphasis on its diagnosis and treatment.

DESIGN

Retrospective case series.

SETTING

Academic medical center.

PATIENTS

Six patients (2 men, 4 women; median age 48 years) received a diagnosis of gastric glomus tumor and were treated.

INTERVENTIONS

Endoscopic diagnosis and resection.

MAIN OUTCOME MEASUREMENTS

Endoscopic features, resection success, adverse events, and follow-up endoscopy.

RESULTS

Gastric glomus tumors do not exhibit specific features on gastroscopy and EUS that distinguish them from other gastric submucosal tumors. Endoscopic submucosal enucleation was successful in 5 patients. In one patient, the operation had to be discontinued because of significant bleeding during the procedure. The mean tumor size was 19.8±6.2 mm (range 12-30 mm). Perforation occurred in 1 patient and was successfully managed with hemoclips. No local recurrence was observed during follow-up (mean duration 9±5.1 months, range 3-17 months).

LIMITATIONS

Small number of patients (N=6), limited follow-up, retrospective study.

CONCLUSIONS

Diagnosis of gastric glomus tumors is difficult when based only on features derived from gastroscopy and EUS. Endoscopic submucosal enucleation is a feasible and safe procedure with which to diagnose and treat this lesion. However, further investigation and comparative studies are required to confirm the safety and efficacy of this method.

Endoscopic full-thickness resection and defect closure in the colon

BACKGROUND

Endoscopic full-thickness resection (eFTR) is a minimally invasive method for en bloc resection of GI lesions.

OBJECTIVE

The aim of this pilot study was to evaluate the feasibility of a grasp-and-snare technique for eFTR combined with an over-the-scope clip (OTSC) for defect closure.

DESIGN

Nonsurvival animal study.

SETTING

Animal laboratory.

ANIMALS

Fourteen female domestic pigs.

INTERVENTIONS

The eFTR was performed in porcine colons using a novel tissue anchor in combination with a standard monofilament snare and 14 mm OTSC. In the first group (n = 20), closure of the colonic defects with OTSC was attempted after the resection. In the second group (n = 8), an endoloop was used to secure the resection base before eFTR was performed.

RESULTS

In the first group (n = 20), eFTR specimens ranged from 2.4 to 5.5 cm in diameter. Successful closure was achieved in 9 out of 20 cases. Mean burst pressure for OTSC closure was 29.2 mm Hg (range, 2-90; SD, 29.92). Injury to adjacent organs occurred in 3 cases. Lumen obstruction due to the OTSC closure occurred in 3 cases. In the second group (n = 8), the diameter of specimens ranged from 1.2 to 2.2 cm. Complete closure was achieved in all cases, with a mean burst pressure of 76.6 mm Hg (range, 35-120; SD, 31). Lumen obstruction due to the endoloop closure occurred in one case. No other complications or injuries were observed in the second group.

LIMITATIONS

Nonsurvival setting.

CONCLUSIONS

Colonic eFTR using the grasp-and-snare technique is feasible in an animal model. Ligation of the resection base with an endoloop before eFTR seems to reduce complication rates and improve closure success and leak test results despite yielding smaller specimens.

Endoscopic closure of gastrogastric fistulas by using a tissue apposition system (with videos)

BACKGROUND

Gastrogastric fistulas (GGFs) are seen in 1.5% to 12.5% of patients after Roux-en-Y gastric bypass (RYGB) bariatric surgery, often leading to failure to lose adequate weight.

OBJECTIVE

The aim of this study was to assess the feasibility, safety, and percentage of successful primary endoluminal closures of GGFs by using a recently developed tissue apposition system in combination with local mucosectomy.

DESIGN

A feasibility and outcome study following institutional review board protocol.

SETTING

Tertiary referral teaching hospital, Legacy Health System, Portland, Oregon.

INTERVENTIONS

A combination of mucosectomy and nonresorbable tissue apposition is used to achieve a permanent closure of the GGF.

PATIENTS

Four patients with 5 GGFs after RYGB; the mean fistula diameter of was 18.6 mm (range 10-30 mm).

RESULTS

Primary closure rate (1 endoscopic session) of 5 GGFs was 100%. The mean procedure time was 88.5 minutes. One to 4 pairs of tissue anchors were used to close the fistulas. The mean time for performing mucosectomy was 21.6 minutes (range 8-42 minutes) and 39.6 minutes (range 12-58 minutes) for fistula closure. Estimated blood loss was on average 2 mL (range 0-5 mL). No complications were recorded. Early success (3 months), as evidenced by early satiety and weight loss, was noted for 3 of 4 patients. After 3 months, only the smallest fistula (10 mm) was still completely closed, and after 6 months, it also showed a pinhole opening.

CONCLUSION

It was feasible to close all fistulas endoscopically without complications. Permanent closure of GGFs could not be achieved.

Endoscopic full-thickness plication for the treatment of gastroesophageal reflux disease using multiple Plicator implants: 12-month multicenter study results

BACKGROUND

The full-thickness Plicator (Ethicon Endosurgery, Sommerville, NJ, USA) was developed for endoscopic treatment of gastroesophageal reflux disease (GERD). The goal is to restructure the antireflux barrier by delivering transmural pledgeted sutures through the gastric cardia. To date, studies using this device have involved the placement of a single suture to create the plication. The purpose of this study was to evaluate the 12-month safety and efficacy of this procedure using multiple implants to restructure the gastroesophageal (GE) junction.

METHODS

A multicenter, prospective, open-label trial was conducted at four tertiary centers. Eligibility criteria included symptomatic GERD [GERD Health-Related Quality-of-Life (GERD-HRQL) questionnaire, off of medication], and pathologic reflux (abnormal 24-h pH) requiring daily proton pump inhibitor therapy. Patients with Barrett's epithelium, esophageal dysmotility, hiatal hernia > 3 cm, and esophagitis (grade III or greater) were excluded. All patients underwent endoscopic full-thickness plication with linear placement of at least two transmural pledgeted sutures in the anterior gastric cardia.

RESULTS

Forty-one patients were treated. Twelve months post treatment, 74% of patients demonstrated improvement in GERD-HRQL scores by > or = 50%, with mean decrease of 17.6 points compared with baseline (7.8 vs. 25.4, p < 0.001). Using an intention-to-treat model, 63% of patients had symptomatic improvements of > or = 50%, with mean GERD-HRQL decrease of 15.0 (11.0 vs. 26.0, p < 0.001). The need for daily proton pump inhibitor (PPI) therapy was eliminated in 69% of patients at 12 months on a per-protocol basis, and 59% on an intention-to-treat basis. Adverse events included postprocedure abdominal pain (44%), shoulder pain (24%), and chest pain (17%). No long-term adverse events occurred.

CONCLUSIONS

Endoscopic full-thickness plication using multiple Plicator implants can be used safely and effectively to improve GERD symptoms and reduce medication use.